Influential characteristics of physician/pharmacist collaborative relationships

Exploring successful community pharmacist-physician collaborative working relationships using mixed methods

BACKGROUND

Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.

OBJECTIVE

To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.

METHODS

A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.

RESULTS

On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.

CONCLUSIONS

The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.

The potency of team-based care interventions for hypertension: a meta-analysis

BACKGROUND

Team-based care is the strategy that has had the greatest effect on improving blood pressure (BP). The purpose of this systematic review was to determine the potency of interventions for BP involving nurses or pharmacists.

METHODS

A MEDLINE search for controlled clinical trials that involved a nurse or pharmacist intervention was conducted. Mean reductions in systolic (S) and diastolic (D) BP were determined by 2 reviewers who independently abstracted data and classified the different intervention components.

RESULTS

Thirty-seven articles met the inclusion criteria. Education about BP medications was significantly associated with a reduction in mean BP (-8.75/-3.60 mm Hg). Other strategies that had large effect sizes on SBP include pharmacist treatment recommendations (-9.30 mm Hg), intervention by nurses (-4.80 mm Hg), and use of a treatment algorithm (-4.00 mm Hg). The odds ratios (95% confidence intervals) for controlled BP were: nurses, 1.69 (1.48-1.93); pharmacists within primary care clinics, 2.17 (1.75-2.68); and community pharmacists, 2.89 (1.83-4.55). Mean (SD) reductions in SBP were: nursing studies, 5.84 (8.05) mm Hg; pharmacists in clinics, 7.76 (7.81) mm Hg; and community pharmacists, 9.31 (5.00) mm Hg. There were no significant differences between the nursing and pharmacy studies (P > or = .19).

CONCLUSIONS

Team-based care was associated with improved BP control, and individual components of the intervention appeared to predict potency. Implementation of new hypertension guidelines should consider changes in health care organizational structure to include important components of team-based care.

Care of the stroke patient-communication between the community pharmacist and prescribers in the Republic of Ireland

OBJECTIVE

This study sought to examine the perceptions that community pharmacists have of communication with prescribers in both primary and secondary care in Ireland, with respect to care of stroke patients.

SETTING

Community pharmacies across Ireland, stratified into the four representative administrative regions.

METHOD

Survey using a structured postal questionnaire.

MAIN OUTCOME MEASURE

Perceptions of communication with prescribers based in primary and secondary care; pharmacy and pharmacy premises demographics.

RESULTS

A response rate of 52% (n = 314) was achieved. Community pharmacists' perceptions of information provision from secondary care were low, the majority (83%) never received any information from the hospital, although they would welcome it. Communication with hospital based prescribers was considered by most (93%) to be poor. The majority (greater than 75%) of respondents expressed a desire for greater information provision concerning a stroke patient's medication and diagnostic information. Pharmacists' perceptions of interaction with general practitioners were generally regarded as good (63%) although information provision in both directions between pharmacist and general practitioner could be improved.

CONCLUSION

The findings of this study indicated that community pharmacists perceive that there is room for improvement in the communication between themselves and prescribers in the primary and secondary care settings, concerning the care of the stroke patient. This highlights the need for the development of formal communication channels between community pharmacists and other members of the healthcare team involved in the care of the stroke patient. However, the challenges of communicating patient information across healthcare sectors are recognized.

Ontario Family Physician Readiness to Collaborate with Community Pharmacists on Drug Therapy Management: Lessons for Pharmacists

Background/Objective:

Collaboration between community pharmacists and physicians with respect to drug therapy management occurs relatively infrequently. There has been little research on physicians' views about such collaboration. The primary objective of this study was to assess Ontario family physicians' attitudes and readiness to collaborate with community pharmacists on drug therapy management.

Methods:

A 3-page survey instrument inquiring about 3 collaborative behaviours was distributed by fax or mail to a random sample of 848 family physicians and general practitioners across Ontario. Nonrespondents received 2 reminders.

Results:

The survey response rate was 36%. Most physicians reported conversing with a community pharmacist about a patient's drug therapy management 5 or fewer times per week, and very few said they used pharmacists as their primary source of medication information. Eighty-four percent reported that they regularly took community pharmacists' phone calls, while 78% reported that they sometimes sought pharmacists' recommendations regarding patient drug therapy. Only 28% reported that they sometimes referred their patients to community pharmacists for medication reviews, with 44% being unaware that such a service existed. Most comments were favourable, typically providing positive examples of collaboration with pharmacists. The most important identified advantage of collaborating with community pharmacists was more accurate medication lists. The main disadvantage identified was that pharmacists are constrained by not having access to key patient information (e.g., diagnosis, lab results, consultant reports). Additional barriers to collaboration reported by physicians included rotating pharmacists and perceived pharmacist interference with physicians' drug therapy plans.

Conclusion:

Overall, Ontario family physicians were engaged in limited collaboration with community pharmacists. By making an effort to increase the frequency of their direct professional interactions with physicians, pharmacists can enhance physician awareness of their willingness to provide patient-oriented services, thus facilitating collaboration.

Taking the lead: community pharmacists' perception of their role potential within the primary care team

BACKGROUND

Patient-focused care provided by an interprofessional team has long been presented as the preferred method of primary care delivery. Community pharmacists should and can provide leadership for many clinical and managerial activities within the primary care team.

OBJECTIVE

To determine the extent to which community pharmacists are prepared to be members of the health care team, and to assess their support for general expansion of clinical responsibilities.

METHODS

A mail questionnaire (in either English or French) was sent to 1500 community pharmacists between February and April 2004. Respondents were asked to indicate the necessity of pharmacy leadership for a range of clinical and managerial services associated with a primary care team. Respondents were also asked to indicate the extent to which they should be more involved in drug therapy selection and monitoring, as well as assuming greater responsibility for treating both minor and chronic illnesses.

RESULTS

The response rate was 35.2% (470/1337) with the highest response rate in the Prairie provinces (40.6%) and the lowest in Quebec (24.4%). Most pharmacists in the study did not advocate a strong leadership role for non-discipline-specific clinical and managerial activities. Most of them indicated that community pharmacists should be more involved in selecting (69.9%) and monitoring (81.0%) drug therapy, and be more responsible for treating minor illnesses (72.0%). Support for more responsibility declined to 50% for chronic illnesses.

CONCLUSIONS

The findings of the study suggest substantial variability among pharmacists in their perception of the need for pharmacy leadership across 16 clinical and managerial activities.

Determinants of the uptake of medicines use reviews (MURs) by community pharmacies in England: a multi-method study

OBJECTIVES

To explore and identify the key determinants influencing the uptake of medicines use reviews (MURs), a new community pharmacy service in England.

METHODS

Survey of all primary care organisations (PCOs) in England (n=303, response rate=74%) and case study investigations of 10 PCOs, involving interviews with a purposive sample of 43 key stakeholders, including PCO, Local Pharmaceutical Committee and community pharmacy representatives. National data on MUR activity were also analysed and multiple linear regression was used to test determinants of MUR uptake.

RESULTS

The ownership category of the pharmacy was shown to be the most significant determinant of MUR uptake. Rates of MUR provision by multiple pharmacies were almost twice that of independent pharmacies. Interview data corroborated this finding, suggesting that organisational pressure within multiple pharmacies was driving forward MUR activity in some PCOs. Interviewees expressed concern about this quantity driven approach. The PCO survey respondents perceived the greatest barrier to MUR implementation to be a lack of support from general practitioners (GPs). Interviewees reported a lack of communication about MURs between community pharmacists and GPs.

CONCLUSIONS

The findings suggest that the organisational setting of the pharmacy is an important factor influencing the uptake of MURs. There is also a need for greater communication and collaboration with GPs regarding the MUR service.

The physical activity counselling (PAC) randomized controlled trial: rationale, methods, and interventions

Primary care is a promising venue to build patient motivation and confidence to increase physical activity (PA). Physician PA counselling has demonstrated some success; however, maintenance of behaviour change appears to require more intensive interventions. In reality, most physicians do not have the necessary training nor the time for this type of counselling. The purpose of this paper is to outline the rationale, methods, and interventions for the ongoing physical activity counselling (PAC) randomized controlled trial (RCT), which aims to assess the impact of integrating a PA counsellor into a primary care practice. This RCT has 2 arms: (i) brief PA counselling (2–4 min) from a health care provider and (ii) brief PA counselling + intensive PA counselling from a PA counsellor (3 months). The impact of this intervention is being evaluated using the comprehensive RE-AIM framework. One hundred twenty insufficiently active adult patients, aged 18 to 69 y and recruited during regular primary care visits have been randomized. Dependent measures include psychological mediators, PA participation, quality of life, and physical and metabolic outcomes. The PAC project represents an innovative, theoretically-based approach to promoting PA in primary care, focusing on psychological mediators of change. We anticipate that key lessons from this study will be useful for shaping future public health interventions, theories, and research.

Mental health case conferences in primary care: Content and treatment decision making

BACKGROUND

Case conferences are multidisciplinary meetings of health professionals to plan treatment for specific people with chronic and complex care needs. The value of multidisciplinary teamwork in mental health care is well recognized.

OBJECTIVE

This study aimed to explore the process of decision making in mental health case conferences involving community pharmacists and primary care physicians.

METHODS

Case conferences were conducted for 44 people receiving one or more medicines for a mental illness. Before participating in the case conferences, pharmacists conducted home visits and produced written reports that detailed Home Medicines Review findings and recommendations. The case conferences were audio taped and transcribed verbatim. A framework, based on the 3 components of decision making (derived from the Model of Shared Decision Making), was used to code statements made at the case conferences. These components were (1) information exchange, (2) deliberation, and (3) decision making.

RESULTS

Pharmacists and physicians exchanged personal and medical information. Pharmacists presented their treatment findings and recommendations, and generally a brief discussion about treatment options followed (deliberation). The responsibility for deciding which treatments to implement (decision) typically remained with the physicians.

CONCLUSIONS

The case conferences provided an opportunity for pharmacists and physicians to share information and discuss treatment options. Responsibility for deciding which treatment to implement generally remained with the primary care physicians.

Survey of pharmacist collaborative drug therapy management in hospitals

PURPOSE

The extent and scope of collaborative drug therapy management (CDTM) in U.S. hospitals and pharmacy directors' perceptions regarding CDTM were studied.

METHODS

A survey was developed after reviewing the literature on CDTM. The sample for the study was obtained from the 2001 American Hospital Association Guide. The mail survey was pretested in January 2002 with 30 hospital pharmacy directors in Illinois, Indiana, and Michigan. A national random sample of 1000 hospital pharmacy directors stratified by state were mailed surveys in March 2003. Two follow-up surveys were mailed at approximately four-week intervals.

RESULTS

Responses were received from 327 hospitals, a 32.7% response rate. A total of 158 respondents (49.7%) indicated that some pharmacists in their hospital were engaged in CDTM. Most hospitals with CDTM authorized pharmacists to adjust a drug's strength (86.7%), order laboratory or related tests (84.2%), and change a drug's frequency of administration (81.6%). The CDTM-related activities pharmacists performed varied with disease and treatment area. Payment or reimbursement for some CDTM was received by 12.7% of hospitals with CDTM. Respondents from hospitals with CDTM perceived significantly greater support for CDTM and greater strategic impact of CDTM than those from hospitals without CDTM. Respondents perceived positive support for CDTM but believed that CDTM had little or no financial impact on pharmacy departments.

CONCLUSION

Approximately 50% of respondent hospitals had some pharmacists engaged in CDTM. Although CDTM was perceived as not having a positive financial impact on pharmacy departments, it was perceived as having a positive strategic impact by improving the views of upper administration regarding the value of pharmacists and facilitating implementation of other pharmacy services.

Utility of a questionnaire to measure physician-pharmacist collaborative relationships

OBJECTIVE

To examine the sensitivity and criterion validity of the 14-item Physician/Pharmacist Collaboration Index (PPCI).

DESIGN

Substudy of an unblinded, randomized trial of pharmacist interventions with patients with uncontrolled hypertension.

SETTING

6 intervention and 6 control pharmacies in eastern Iowa.

PARTICIPANTS

25 community pharmacists.

INTERVENTIONS

Pharmacists completed the PPCI at baseline and at a 3-month follow-up for each patient's physician.

MAIN OUTCOME MEASURES

Respondents' perceptions about their relationships with each patient's physicians as measured through scores in three domains, Trustworthiness (TW; score range, 6-42), Role Specification (RS, 5-35), Relationship Initiation (RI, 3-21), and compared using nonparametric tests.

RESULTS

Pharmacists' mean scores of their relations with 38 different physicians (54 completed PPCIs) in the intervention group were 33.8 for TW, 23.2 for RS, and 16.4 for RI at baseline. At 3 months, the scores had improved significantly to 35.5, 25.0, and 17.4, respectively. Pharmacists' scores for 43 different physicians (49 completed PPCIs) in the control group did not change significantly between baseline and 3 months (TW, 30.7 at each time point; RS, 20.3 and 19.7, respectively; RI, 14.3 at each time point).

CONCLUSION

Improved scores in the intervention group suggest that collaborative relations improved between the physician and pharmacist during the 3-month study, while no such improvement was found in the control group. Since the intervention was designed to promote collaboration between pharmacists and physicians, these results support the PPCI as a tool to measure pharmacist-physician collaboration and could be used by pharmacists to benchmark collaborative relationships. Additional research is needed to corroborate the results of this study.

Improving communication skills of pharmacy students through effective precepting

Pharmacy students should be given opportunities to learn and practice interpersonal communication skills during their community advanced pharmacy practice experience (APPE). Preceptors have the responsibility of setting the stage for the pharmacy students during their initial encounter. During this orientation to the site, students should become familiar with the history of the practice, the types of services provided, and the staff members. Once the orientation is completed, preceptors can develop strategies for incorporating the students into the practice's patient care activities. Students should participate in patient counseling, interviewing, and educational sessions. Also, students should participate in collaborative work with other health care providers. To ensure the development of communication skills in pharmacy students, preceptors can incorporate the teaching process "see one, do one, teach one" into their teaching activities. By following these strategies, preceptors can effectively and positively impact the communication skills of their students.

Factors affecting collaborative care between pharmacists and physicians

BACKGROUND

To have a positive impact on patient outcomes achieved with drug therapy, it is likely that pharmacists will work more closely with physicians to manage medications collaboratively. Yet, little is known about the factors that will support such collaborative care between pharmacists and physicians.

OBJECTIVE

The objective of this study was to identify significant influences on collaborative care between pharmacists and physicians, from the perspective of pharmacists.

METHODS

Data were collected through a survey mailed to a national sample of 321 pharmacists identified by state pharmacy associations as being innovative practitioners. Three types of influences were assessed: individual characteristics, contextual factors, and exchange characteristics. Individual characteristics included demographics and a personality measure. Context variables included practice environment and professional interactions between pharmacists and physicians. Exchange characteristics were trustworthiness, role specification, and relationship initiation. Four items asked about the pharmacist's collaborative care with a physician. A hierarchical linear regression analysis was performed with collaborative care as the dependent variable and the individual, context, and exchange characteristics as the independent variables.

RESULTS

One hundred sixty-six usable surveys (53.4%) were returned. About 64% of the respondents were male, with a mean age of 43.7 (SD+/-11.2) years. Linear regression analysis of the complete model produced an R(2)=0.805 (P<.001). Significant predictors in the model included the context variable, professional interaction, and the exchange characteristics, trustworthiness and role specification.

CONCLUSION

Overall, the collaborative working relationship model largely explained collaborative care between pharmacists and physicians. Researchers are encouraged to use these findings when studying pharmacist-physician collaboration. In addition, pharmacists seeking to work with physicians should attend to developing trustworthiness and clarifying their clinical roles with physicians.

Comprehensive Medication Therapy Management: Identifying and Resolving Drug-Related Issues in a Community Pharmacy

OBJECTIVE

The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them.

METHODS

In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patient's physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations.

RESULTS

Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%).

CONCLUSION

The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.